The term haematemesis or vomiting of blood is applied to bringing blood up from the stomach, no matter what the source may be. Haematemesis may be due to bleeding of the stomach or parts of the body somewhat remote from that organ. The blood may have been swallowed after the removal of teeth, tonsils, adenoids, from wounds or ulcers about the mouth or throat. Profuse bleeding of the nose may occur without obvious reason if the blood-vessels are diseased, and a large amount of blood may unconsciously be swallowed. Much blood may trickle down the throat when the base of the skull is fractured; but in such cases there is usually some circumstantial evidence of injury. In some cases of profuse haemoptysis blood may be swallowed. If the haemoptysis is due to tuberculosis there will probably be a history of cough and night sweats. But it might be due to the rupture of an aneurism of the aorta or some branch of the pulmonary artery, the haemorrhage being profuse and usually fatal. The blood might also come from cancer of the gullet or an acute inflammation of that channel from the action of a corrosive poison.

Bleeding from the stomach itself may be due to a variety of causes. It may result from congestion of the vessels due to mechanical obstruction to the circulation from diseases of the heart or liver, which sometimes cause profuse bleeding. Very profuse bleeding of the stomach may also occur as the result of gastric ulcer, cancer, or corrosion of bloodvessels by the local action of powerful acids and other poisons. Slight bleeding of the stomach may occur in the course of acute gastritis, chronic gastritis, or cancer. Bleeding of the stomach may also occur in acute fevers, Bright's disease, scurvy, purpura, and in that peculiar condition known as haemophilia which exists in persons called "bleeders". It may also occur as the result of "vicarious menstruation"; this has been doubted, but it is an indisputable fact that women who have a deficient menstrual flow are liable to bleeding from the stomach and other parts of the body without obvious cause. Excessive vomiting from any cause may make the stomach bleed. Finally, blood may be vomited from the stomach of malingerers who have actually swallowed it; and other fluids, coloured like blood, may also be swallowed and vomited by such people with the idea of obtaining pity and possibly exemption from duty.

It may be assumed, as a general rule, that bleeding from the gullet, stomach, or duodenum is attended by vomiting of blood, and that, with few exceptions, bleeding from any part of the bowels below the duodenum never gives rise to vomiting, but in such cases the blood is voided solely by the anus and gives rise to melcena or blood in the motions. Although it is the rule for bleeding from the gullet, stomach, and duodenum to give rise to vomiting of blood, it must never be forgotten that in almost all cases some of the blood passes into the bowels, and that in other cases there may be no vomiting, but all the blood passes through the bowels.

The recognition of blood in the vomit or faeces is not usually difficult. Vomited blood is generally of a dark colour, but is occasionally of a bright arterial tint, and it may be fluid or in clots. If vomiting does not occur immediately after bleeding the blood undergoes a change in appearance owing to the action of gastric juice upon it, when it acquires the character known as "coffee-grounds". Blood from the bowels may be of a dark chocolate colour or of a pitchy character. In doubtful cases, due to the small amount of blood, the aid of the microscope or chemical tests may be required. It is important not to confound the discoloration of the vomit due to wine, iron, bismuth and other drugs with that dependent on the presence of blood.

The symptoms arising from bleeding of the stomach naturally vary with the amount of blood lost and its cause. In acute febrile diseases, pyaemia, septicaemia, anaemia, the bleeding is only a symptom adding severity to the primary affection, and it materially increases the gravity of the case. But when haematemesis occurs from an ulcer of the stomach, cirrhosis of the liver, or aneurism of a blood-vessel, definite symptoms occur. In these cases the haemorrhage not infrequently happens after some indiscretion on the part of the patient, such as the consumption of indigestible food, a drinking bout, or unusual exertion. Prior to the vomiting the patient suddenly feels faint, turns pale, and complains of a sensation of sinking or actual pain. Some patients fall down insensible or convulsed, or appear to be at the commencement of an epileptic seizure. In less severe cases the faintness is succeeded by coldness of the skin, perhaps a cold sweat, and a small, infrequent, and compressible pulse. These symptoms are due to the loss of blood. If the bleeding is slight there may be no vomiting, but if it is excessive or continuous, vomiting of blood usually occurs and the cause of the faintness is evident.

After the faintness and vomiting have passed away there is, in the majority of cases, a stage of reaction. While loss of blood leaves the patient bleached and the temperature depressed, the pulse now becomes full and bounding, but it is very soft and compressible, and eventually slows down. A tinge of colour also appears on the cheeks, and is in marked contrast to the marble-like appearance of the rest of the skin, and the patient may become restless and excitable. Bleeding from an ulcer of the stomach is rarely fatal immediately, nor is that from cancer; but when the bleeding is due to cirrhosis of the liver death may be very speedy.

The measures to be taken for the arrest of bleeding from the stomach are practically the same as those adopted for bleeding in other parts of the body. The very essence of such treatment is rest - local and general rest. This is obtained by putting the patient to bed and in the recumbent posture, avoiding all unnecessary movements, and guarding against mental excitement. The latter will require the exclusion of all friends from the room, especially "fussy" relatives, and permitting the presence of those persons only who are required to assist in carrying out medical instructions. Rest of the stomach is obtained by refraining from the administration of any food by the mouth, and by giving only those liquids which will assist in checking the bleeding and vomiting. The administration of stimulants by the mouth must also be forbidden. We may allow the patient to suck some ice or to drink ice-water, or other water which contains the drugs prescribed by the doctor. Alum-whey may be given in doses of one ounce every hour. It is made as follows: Take 1 pint of boiling milk; dissolve 1/4 ounce of powdered alum in 2 ounces of hot water; mix it in the milk, stir; let it stand a few minutes and strain it. This is not only nutritious, but, being astringent, will assist in stopping the haemorrhage. But a large quantity of fluids cannot be allowed, because it would encourage vomiting, cause a recurrence of bleeding, and probably reopen a vessel which is already closed. Nature's method of arresting bleeding is to form a clot of blood in the interior of the injured vessel up to the nearest branch. To assist in bringing this about she endows the blood with the property of forming a blood-clot. Such a clot is formed first of all outside the blood-vessel - in this case it is formed in the cavity of the stomach ; the clot so formed temporarily blocks up the gap in the blood-vessel, and by this means favours the formation of a blood-clot in the interior of the vessel. The object of our treatment is to encourage the formation of the clot in the interior, to prevent a clot so formed from getting dislodged by bodily movements or vascular excitement, and give it time to become firm. The application of an ice-bag or ice-poultice over the epigastrium will materially assist our endeavours.

The question arises as to what should be done to rally the patient from fainting. Unless it is a serious case of syncope or collapse, it is not advisable to use vigorous measures at first for fear of producing a too speedy reaction and causing the vessel to bleed afresh. By no means should stimulants be given by the mouth or the circulation stimulated by rubbing the extremities. Let the legs and feet be raised well above the level of the body by pillows or cushions, and the head kept low. Apply a damp cloth to the forehead and temples, and let it be perfumed with eau de Cologne, eau de Florida, or sal volatile. If the patient is actually unconscious a bottle of smelling-salts may be applied to the nostrils, and half an ounce to an ounce of brandy with as much water injected into the rectum will be useful. These procedures will generally help the patient to rally, the recovery being indicated by a return of consciousness, an improvement of the pulse, and perhaps a little colour in the cheeks.

There are some cases where the bleeding is so profuse and the collapse or unconsciousness so prolonged as to necessitate the use of other measures. These consist of the transfusion of blood and injection of saline solutions. The former mode of treatment is rarely adopted. But the injection of saline solution is often practised and is an extremely useful measure. The solution most commonly used consists of two teaspoonfuls of common salt in two pints of boiled water, cooled down to 1050F. It is injected, or allowed to find its way by gravitation, through a large hollow needle or trocar inserted into the subcutaneous tissues of the armpit, the loose tissues of the breasts, or other parts of the body. The effect is often marvellous, and shows itself primarily in the improvement of the pulse and increased blood-pressure.

The foregoing account shows that vomiting blood may be due to many causes. But two chief causes are most often met with. These are chronic ulcers of the stomach and cirrhosis of the liver. The former occurs in young women, and there is a history of long-continued dyspepsia and anaemia prior to the bleeding. The latter occurs chiefly in males; there is probably dropsy of the abdomen at the time the haemorrhage occurs, and a history of chronic alcoholism. In both cases the haemorrhage is serious. But it is far more serious when it occurs in persons already debilitated by disease and may cause death. When the bleeding is due to cirrhosis of the liver some authorities recommend the use of purgatives to relieve the congestion of the portal vessels, but this is a dangerous practice, and contrary to the first rule for the treatment of bleeding - viz., rest.

When the haemorrhage ceases and the stage of reaction sets in sedatives may be required, and the continuance of rest and quietude is absolutely essential. The feeding should be entirely rectal for a day or two if the blood has come from the gullet, stomach, or bowels. When stomach feeding is commenced the food will necessarily be light and of a kind easily digested, but the kind and the amount will depend upon the nature of the causative disease.